Does Family Structure Play a Role in Depression in Adolescents Admitted to Psychiatric Inpatient Care?

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1 Child Psychiatry Hum Dev (2016) 47: DOI /s ORIGINAL ARTICLE Does Family Structure Play a Role in Depression in Adolescents Admitted to Psychiatric Inpatient Care? Matti Laukkanen 1,2 Helinä Hakko 1 Pirkko Riipinen 1,2 Kaisa Riala 3 Published online: 14 January 2016 Springer Science+Business Media New York 2016 Abstract We examined whether adolescents family structure associate with depression in a clinical sample of 508 adolescents (age years) treated in psychiatric hospital between April 2001 and March Psychiatric disorders of adolescents were based on the K-SADS-PLinterview. Adolescents with depression were characterized by a single parent family background (58 %), but less commonly by a child welfare placement (37 %). Depression in adolescents was significantly related to female gender and a single parent family background, but less significantly related to comorbid psychotic or conducts disorders. The association between family structure and depression presents a challenge to mental health services. Early screening for depression in adolescents admitted for psychiatric treatment from at risk family types is important to enhance their future wellbeing and coping strategies. Keywords Adolescent Depression Mental disorders Nuclear family Blended family Single parent family & Matti Laukkanen matti.laukkanen@ppshp.fi Department of Psychiatry, Oulu University Hospital, PO Box 26, OYS Oulu, Finland Department of Psychiatry, Institute of Clinical Medicine, University of Oulu, Oulu, Finland Department of Adolescent Psychiatry, Helsinki University Central Hospital, Helsinki, Finland Introduction Family structures have undergone significant changes in Western societies over the past few decades. These changes in family structure are related to general demographic trends, such as postponement of family formation and the instability of married and unmarried partnerships [1, 2]. There has also been a transition away from the traditional family of two biological parents to other compositions, such as single parent or blended families. In Finland changes in family structure have also been apparent, with the proportion of single parent families increasing by 40 % between 1980 (84,490) and 2013 (118,315). Blended families accounted for 6.9 % of all families with children in Finland in 1990 and 9.2 % by 2013 [3]. Childhood family instability, which may partly be a consequence of changes in family structure, has been shown to have long-lasting negative effects on mental health, including internalizing problems [4]. Adolescents from a single-parent family background have been reported to suffer more commonly from depression than those from a two-parent family background [5 8]. The transition from two biological parent families to single-mother family or cohabiting stepfamily units has been shown to increase the likelihood for depression in a general population sample of adolescents with an average age of 15-years [1]. With family transition in our society still ongoing, it is necessary to examine the impact these changes have on children s psychological well-being. Since low social support for the family is associated with depression in adolescence [9], we felt it important to examine whether the prevalence and severity of depression differs between young adolescents admitted to psychiatric hospital from different family structures. Further, we wanted to determine the factors underlying admissions to psychiatric

2 Child Psychiatry Hum Dev (2016) 47: hospitals from different types of family when adolescents required hospitalization due to acute psychiatric illness. Materials and Methods Study Sample The present study is part of a clinical follow-up project called Study-70, which was initiated to examine the long-term outcomes of adolescents treated in psychiatric hospital for severe mental disorders. The original sample consisted of 508 adolescent inpatients (208 males, 41 %, and 300 females, 59 %) aged years (M = 15.4 years, SD = 1.3) consecutively admitted to Unit 70 at Oulu University Hospital, Department of Psychiatry, between April 2001 and March The catchment area of Unit 70 of Oulu University Hospital covers the regions of Oulu and Lapland. All adolescents from this area in need of acute psychiatric hospitalization in a closed ward were initially treated at Unit 70. In the study sample, 98.4 % of the adolescents were Caucasian and only 1.6 % had another ethnic background. Following admission to unit 70, the subjects and their parents (or guardian) were asked about their interest in participation in Study-70. Signed informed consent was required from both the subject and at least one parent (or guardian) before allowing an adolescent s participation in the study. Subjects aged over 18 years, or who had intellectual disability or organic brain disorders or who did not provide written informed consent for participation were excluded from the data % of the eligible adolescents participated in the study. Research Instruments All participants were interviewed using several research instruments. DSM-IV diagnoses were determined by using the semi-structured Schedule for Affective Disorder and Schizophrenia for School-Age Children, Present and Lifetime (K-SADS-PL) interview [10]. The face-to-face structured interview was completed using the European modification of the Addiction Severity Index (EuropASI) instrument in order to gather information on various aspects of each adolescent s life, such as physical health, family structure and social conditions [11]. Family Structure The information regarding the adolescents family type was obtained from the K-SADS-PL interview. Family type was categorized as follows: (1) Two-parent family (biological mother and biological father); (2) Blended family (Biological mother or biological father with a married or cohabiting partner); (3) Single-parent family (one biological parent); (4) Foster family (adoptive/foster parents, grandparents, other relatives, non-relatives); (5) Child welfare placement (Children s home or family community home); and (6) Other home environment (Living alone, residential home). The distribution of the various family types is presented in Table 1. In light of the small sample size (9 boys and 28 girls) and heterogeneity of the other home environment group, this group was excluded from subsequent statistical analyses. The final study sample for the current study was 471 adolescents (199 boys, 272 girls). Definition of Depression The definition of depression was based on the K-SADS-PL interview and used the following DSM-IV diagnostic codes: 296.2, major depressive disorder (MDD), single episode (n = 151); 296.3, MDD, recurrent (n = 10); 296.9, mood disorder NOS (n = 1); , dysthymic disorder (n = 3); , cyclothymic disorder (n = 1); and 311, depressive disorder NOS (n = 54). The severity of affective disorder was determined according to the DSM-IV diagnostic criteria as follows: (1) mild, , 296.9, 311.x (n = 71), (2) moderate, , (n = 104), and (3) severe, including psychotic depression, ,.30,. 33, (n = 40, including 9 psychotic depression). The assessment of severity could not be reliably made for diagnoses (MDD, recurrent, in partial remission) (n = 1), (cyclothymic disorder) (n = 1) and , dysthymic disorder (n = 3). Causes for Admission Causes for admission to hospital were based on the information gathered on admission to psychiatric inpatient care. This information was categorized as follows: depressive mood, suicidality (including suicidal ideation and behaviour), psychotic symptoms, anxiety or sleep problems, substance use, behavioural problems and aggression. Cause of admission was based on the judgement of the treating physician or nurse in co-operation with the adolescent patient and/or their parent(s)/guardian(s) on admission to the psychiatric hospital. Some patients had several reasons for admission. Covariates Educational level and employment status of the parents of each adolescent was used to determine the socio-economic status of the parents. The mother and father s educational level and employment status were obtained from the EuropASI. Levels of professional educational involved the following categories: (1) None/not known (only compulsory education), (2) Student or vocational courses, (3) Vocational qualification (upper secondary education), and (4) Higher educational degree (polytechnic, university). The

3 920 Child Psychiatry Hum Dev (2016) 47: Table 1 Family structure at admission for psychiatric inpatient care Gender of adolescents Total (n = 508) Boys (n = 208) Girls (n = 300) Family type n (%) n (%) n (%) Two-parent family 189 (37.2) 57 (27.4) 132 (44.0) Blended family 58 (11.4) 39 (14.4) 28 (9.3) Single parent family 97 (19.1) 41 (19.7) 56 (18.7) Foster Family 38 (7.5) 19 (9.1) 19 (6.3) Child welfare placement 89 (17.5) 52 (25.0) 37 (12.3) Other home environment 37 (7.3) 9 (4.3) 28 (93.3) employment status indicates whether or not an adolescent s mother or father has part- or full-time work (yes, no). Comorbid psychiatric diagnoses were based on the K-SADS-PL interview. The categories of comorbid psychiatric diagnoses according to DSM-IV criteria were as follows: (1) Substance-related disorders (303.9, , , 305.0, , 305.9), (2) Anxiety disorders ( , , , 300.3, 308.3, ), (3) Conduct and oppositional defiant disorders ( , , 314, ), and (4) Psychotic disorders (295, 296.0, , , , ). Diagnoses occasionally overlapped, with some patients having several psychiatric diagnoses. Statistical Methods Statistical significance of group differences in categorical variables was assessed using Pearson Chi Square test or Fisher s Exact test, and in continuous variables using Student s t test or Mann Whitney U-test. The association of family structure with depression in adolescents was examined using a logistic regression analysis after controlling for parents education and employment status and adolescent s comorbid psychiatric disorders (conduct, anxiety, psychotic and substance use related disorders) and interaction term for gender and family type. The statistical software used in analyses was the PASW Statistics 18. All statistical tests were two-tailed and a limit for statistical significance was set at p B The research plan for the Study-70 project which the present research is part of was reviewed and approved by the Ethics Committee of the Faculty of Medicine, University of Oulu, Finland, on 11th April Results Prevalence of Depression Depression was present in 220 (46.7 %) adolescents, and was more common in girls 153 (56.3 %) than boys 67 (33.7 %) (p \.001). Of the total depressed adolescents, 71 (33.0 %) had mild, 104 (48.4 %) moderate and 40 (18.6 %) severe depression. Characteristics of Depressed Adolescents Characteristics of the study sample by depression status are presented in Table 2. Adolescents depression was not found to be associated with the educational level or current employment status of the parents. Adolescents with a background of depression were statistically significantly more likely to have depressive mood (p \.001) and suicidality (p \.001) and less commonly psychotic symptoms (p \.001) or behavioral problems or aggressiveness (p \.001) as the cause for admission to psychiatric hospital compared with adolescents without depression. Adolescents with depression were less likely to be admitted due to comorbid conduct disorder (p \.001) or psychotic disorders (p \.001) than adolescents without depression. Depression and Family Structure As shown in Fig. 1, adolescents with depression were more commonly admitted for psychiatric inpatient care from a single parent family (58 %), but less commonly from a child welfare placement (37 %). A statistically significant greater proportion of adolescent girls, compared to boys, with depression had a family comprising of two biological parents (boys vs. girls: 29.8 % vs %, p =.003) or a single parent (43.9 % vs %, p =.018) or they came from a child welfare placement (23.1 % vs %, p =.001), while no gender difference was observed among adolescents from blended families (43.3 % vs %, p = 0.44) or those living in foster families (36.8 % vs %, p =.51). Table 3 presents the distribution of severity of depression in adolescents from different family types. Adolescents from child welfare placements more commonly had

4 Child Psychiatry Hum Dev (2016) 47: Table 2 Depression in relation to socio-demographic, causes for psychiatric admission and clinical characteristic of adolescent psychiatric inpatient boys and girls Total sample Yes (n = 220) No (n = 251) n (%) n (%) p Professional education of parents Mother s education.77 None/not known Courses/student Vocational school University level of education 59 (26.8) 53 (24.1) 62 (28.2) 46 (20.9) 57 (22.7) 65 (25.9) 76 (30.3) 53 (21.1) Father s education.70 None/not known Courses/student Vocational school University level of education 79 (35.9) 36 (16.4) 76 (34.5) 29 (13.2) 83 (33.1) 48 (19.1) 81 (32.3) 39 (15.5) Working status of parents Mother unemployed 88 (40.0) 107 (42.6).56 Father unemployed 89 (40.5) 96 (38.2).62 Reasons for psychiatric admission Depressive mood 115 (52.3) 49 (19.5) \.001 Suicidality 103 (46.8) 65 (25.9) \.001 Psychotic symptoms 10 (4.5) 50 (19.9) \.001 Anxiety or sleep problems 37 (16.8) 50 (19.9).39 Substance use 15 (6.8) 25 (10.0).22 Behavioral problems or aggression 39 (17.7) 83 (33.3) \.001 Psychiatric disorders of adolescent at psychiatric inpatient care a Conduct disorders 73 (33.2) 139 (55.4) \.001 Substance use related disorders 74 (36.6) 97 (38.6).26 Anxiety disorders 55 (25.0) 48 (19.1).12 Psychotic disorder 13 (5.9) 54 (21.5) \.001 a In depressed adolescents indicates comorbid psychiatric diagnoses and in non-depressed adolescent the prevalence of psychiatric disorders mild or moderate depression (p =.040) compared to all other family types. Cause of Admission and Family Structure Table 4 shows that the family type of adolescents with depression did not statistically significantly associate with the cause for admission to psychiatric inpatient care. Family Type as Predictor for Depression Table 5 shows that statistically significant predictors for adolescent depression were an adolescent s female gender (p \.004) and single family background (p =.026). Further, depressed adolescents had a decreased likelihood of having comorbid conduct (p \.001) or psychotic (p \.001) disorders. No statistically significant interactions were found for gender and or family type. Discussion Summary of Main Results The results of our study showed that the risk for depression is doubled in adolescents from single parent families. Depressive mood and suicidality were the most common reasons for psychiatric hospital admission among adolescents with depression. Strength and Weaknesses of the Study The strength of our study is that the adolescents psychiatric disorders were assessed using the K-SADS-PL interview, which has an evidence base demonstrating good psychometric properties for the screening and diagnoses of DSM-IV disorders in adolescent populations [10]. Our study was conducted in a large sample of adolescents admitted to inpatient psychiatric care from a

5 922 Child Psychiatry Hum Dev (2016) 47: Fig. 1 Prevalence of depression in adolescents admitting to psychiatric inpatient treatment from different family structures Table 3 Family structure and severity of depression in adolescent boys and girls Severity of depression Mild (n = 71) Moderate (n = 104) Severe (n = 40) n (%) n (%) n (%) p a Group difference Total sample Two biological parent 29 (34.1) 36 (42.4) 20 (23.5).23 Blended family 13 (48.1) 11 (40.7) 3 (11.1).18 Single parent family 11 (20.0) 32 (58.2) 12 (21.8).06 Foster family 4 (26.7) 7 (46.7) 4 (26.7).68 Child welfare placement 14 (42.4) 18 (54.5) 1 (0.0).040 Details of the severity of depression was missing for 5 adolescents (2 boys, 3 girls) a p indicates the statistical significance of difference between family type in question versus rest of the family types geographically large area in Northern Finland which covers about 45 % of the area of Finland. The patients represent the most serious cases in the young adolescent population of that area. This limits the generalization of our findings to the entire Finnish adolescent population. Our findings also cannot be generalized to populations other than Caucasians. Another limitation of our study is that our database does not measure whether adolescents had experienced a transition, or at what age and how many times a transition may have occurred during each adolescent s lifetime. Our measurement of the severity of depression was based on the DSM-IV diagnosis set at the K-SADS-PL interview. Additional data, such as symptom counts or information on functional impairment may have allowed more accurate measures of the level of depression. The small number of cases in some subgroups may have reduced the power in statistical analyses, thus causing Type II errors. Since many statistical comparisons were performed in our study, a risk of spurious findings (Type I error) may also exist. Comparison with Existing Literature Several epidemiological studies have reported a positive association between adolescent depression and single parent status [1, 5]. Our results are in line with those studies. One explanation may relate to reduced parental skills. In a single parent family, the parent is usually solely responsible their children s physical and emotional well-being and may not have enough time to attend to their children s basic needs [7]. When the association of a parent s educational level and employment status to their child s depression was examined, no significant association was observed. This contradicts the findings of many previous studies

6 Child Psychiatry Hum Dev (2016) 47: Table 4 Reasons for psychiatric hospital admission among depressive adolescents from various family types Reason for admission Two biological parents Blended family Single parent family Foster family Child welfare Group (n = 87) (n = 28) (n = 56) (n = 16) placement (n = 33) difference n (%) n (%) n (%) n (%) n (%) p Depressive mood.24 No 43 (49.4) 13 (46.4) 21 (37.5) 11 (68.8) 17 (51.5) Yes 44 (50.6) 15 (53.6) 35 (62.5) 5 (31.3) 16 (48.5) Suicidality.76 No 45 (38.5) 16 (13.7) 33 (28.2) 8 (6.8) 15 (12.8) Yes 42 (40.8) 12 (11.7) 23 (22.3) 8 (7.8) 18 (17.5) Anxiety and sleep problems.93 No 72 (39.3) 22 (12.0) 48 (26.2) 13 (7.1) 28 (15.3) Yes 15 (40.5) 6 (16.2) 8 (21.6) 3 (8.1) 5 (13.5) Psychotic symptoms.76 No 83 (39.5) 28 (13.3) 53 (25.2) 15 (7.1) 31 (14.8) Yes 4 (40.0) 0 3 (30.0) 1 (10.0) 2 (20.0) Behavioral problems or aggression.06 No 76 (42.0) 22 (12.2) 49 (27.1) 12 (6.6) 22 (12.2) Yes 11 (28.2) 6 (15.4) 7 (17.9) 4 (10.3) 11 (28.2) Substance use.47 No 83 (40.5) 25 (12.2) 50 (24.4) 16 (7.8) 31 (15.1) Yes 4 (26.7) 3 (20.0) 6 (40.0) 0 2 (13.3) A patient can have several causes of admission simultaneously Table 5 Statistically significant predictors for depression in adolescent psychiatric inpatients Predictors B SE Wald OR 95 % CI of OR P Gender, female \.001 Single parent family Statistically significant covariates Conduct disorders \.001 Psychotic disorders \.001 Odds Ratios (ORs) with 95 % Confidence Intervals (95 % CIs) are adjusted for age (method = enter) and, by using stepwise selection criteria (method = LR), for mother s and father s educational level and employment status, adolescent s co-morbid psychiatric disorders (conduct, anxiety, psychotic and substance use related disorder) and interaction term for gender * family type. Only the statistically significant results are reported in the table reporting adolescent depression to be related to a parent s academic and employment status [12 15]. In Finland the educational system offers equal opportunities of education for all, irrespective of matters of residency, sex, economic situation or linguistic and cultural background [16]. Therefore, the impact of a parent s socio-economical background is perhaps not emphasized in Finnish adolescents well-being. Adolescent boys from blended and single parent families had the highest prevalence of depression. In our data, 30 % of males and 53 % of females had been admitted for treatment from families with two biological parents. In males, this differs markedly when compared to the general 1987 Finnish birth cohort of the same age range (males 59 %, females 57 %) [17]. Further, adolescent boys from child welfare placements had the lowest prevalence of depression. This may be because the most common reason for child welfare placement in boys is behavioral problems [18]. Conversely, depression in boys may be masked by externally directed behavioral problems, which may lead to an increased likelihood for risk behavior, such as violent or risk taking acts [19]. A challenge is to separate masked depression in boys behind externalizing symptoms. This challenge requires further studies.

7 924 Child Psychiatry Hum Dev (2016) 47: Summary Parenting skills may be affected by the absence of a cohabiting parent [7] and should be a key focus when offering psychosocial support to parents of adolescents with mental health problems. This parental support, whether provided by mental health care services or social service authorities, should be relevant to their current circumstances not only during an adolescent s psychiatric inpatient care but also after discharge from hospital. It should also be designed to help adolescents identify and cope with difficulties in their future psychosocial development [20]. It is important to recognize the signs and symptoms of depression beyond the more typical presentation, particularly in boys whose depression may be masked by behavioral symptoms. Information on the family type of adolescents is an important background factor when assessing the living conditions and social support available for adolescents presenting with depression. Early screening for depression in adolescents from at risk family types is essential in order to enhance their coping strategies and act to prevent more serious psychiatric problems developing in the future. Compliance with Ethical Standards Conflict of interest None. Ethical Approval Adolescent patients, who fulfilled the inclusion criteria, and their parents or guardians were given written and verbal information on the study and asked for informed consent. The research plan for the STUDY-70 project which the present research if part of was reviewed and approved by the Ethics Committee of the Faculty of Medicine, University of Oulu, Finland, on 11th April References 1. Brown SL (2006) Family structure transitions and adolescent well-being. Demography 43: Daly M (2001) Changing family life in Europe: significance for state and society. Eur Soc 5: Official Statistics of Finland (2013) Families [e-publication]. Appendix table 1. Families by type in Statistics Finland. Accessed 14 Apr Bakker MP, Ormel J, Verhulst FC, Oldehinkel AJ (2012) Childhood family instability and mental health problems during late adolescence: a test of two mediation models the TRAILS study. J Clin Child Adolesc Psychol 41: Mäkikyrö T, Sauvola A, Moring J, Veijola J, Nieminen P, Järvelin M-R, Isohanni M (1998) Hospital-treated psychiatric disorders in adults with a single-parent and two-parent family background: a 28 year follow-up of the 1966 Northern Finland Birth Cohort. Fam Process 37: O Connor TG, Thorpe K, Dunn J, Golding J (1999) Parental divorce and adjustment in adulthood: findings from a community sample. J Child Psychol Psychiatry 40: Waldfogel J, Craigie T, Brooks-Gunn J (2010) Fragile families and child wellbeing. Future Child 20: Zeiders KH, Roosa M, Tein J (2011) Family structure and family processes in Mexican American families. Fam Process 50: Väänänen JM, Marttunen M, Helminen M, Kaltiala-Heino R (2014) Low perceived social support predicts later depression but not social phobia in middle adolescence. Health Psychol Behav Med 2: Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, Williamson D, Ryan N (1997) schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36: Kokkevi A, Hatgers C (1995) European adaptation of a multidimensional assessment instrument for drug and alcohol dependents. Eur Add Res 1: McLaughlin KA, Breslau J, Green JG, Lakoma MD, Sampson NA, Zaslavsky AM, Kessler RC (2011) Childhood socio-economic status and the onset, persistence, and severity of DSM-IV mental disorders in a US national sample. Soc Sci Med 73: McLaughlin K, Costello J, Leblanc W, Sampson N, Kessler R (2012) Socioeconomic status and adolescent Mental Disorders. Am J Public Health 102: Gilman SE, Kawachi I, Fitzmaurice GM, Buka SL (2002) Socioeconomic status in childhood and the lifetime risk of major depression. Int J Epidemiol 31: Huurre T, Eerola M, Rahkonen O, Aro H (2007) Does social support affect the relationship between socioeconomic status and depression? A longitudinal study from adolescence to adulthood. J Affect Disord 100: Study in Finland: Education system in Finland, updated cation_system).accessed 14 Apr Paananen R, Gissler M (2012) Cohort profile: the 1987 Finnish Birth Cohort. Int J Epidemiol 41: Baker AJ, Archer M, Curtis P (2007) Youth characteristics associated with behavioral and mental health problems during the transition to residential treatment centers: the Odyssey Project population. Child Welfare 86: Bhatia SK, Bhatia SC (2007) Childhood and adolescent depression. Am Fam Physician 75: Laukkanen E, Hintikka J, Kylmä J, Kekkonen V, Marttunen M (2010) A brief intervention is sufficient for many adolescents seeking help from low threshold adolescent psychiatric services. BMC Health Serv Res 10:261